Betegtörténet

Betegtörténet is the term used in Hungarian medical practice to describe the narrative record of a patient's health status, as provided by the patient or caregivers. In English, it is commonly referred to as patient history or anamnesis. The betegtörténet comprises several elements: a presenting complaint (a description of the symptoms and reasons for seeking care, including onset, course, and associated factors), past medical history (previous illnesses, surgeries, hospitalizations), medications (current and recent medications, including over-the-counter drugs and supplements), allergies and adverse reactions, immunization status, and family and social history (family diseases, smoking, alcohol, drug use, occupation, living arrangements). A structured review of systems may be documented to identify symptoms related to organ systems.

The information is gathered primarily through clinician-patient interview, sometimes with input from family members or prior records. Accuracy depends on patient recall, comprehension, and communication, and clinicians may verify or supplement the history with other data such as previous records, laboratory results, or physical examination findings. The betegtörténet informs differential diagnosis, risk assessment, and treatment planning, and is a fundamental component of medical documentation in electronic health records. In research and quality improvement contexts, aggregated or de-identified betegtörténet data may be used with proper consent and approvals.

Privacy and confidentiality are essential; in Hungary and the EU, health data are subject to legal protections, and patients generally have rights to access and request corrections to their records. The betegtörténet is updated at each visit to reflect new information and changes in health status.